Early rehospitalization after kidney transplantation (KT) is common and may predict future adverse outcomes. Previous studies using claims data have been limited in identifying preventable rehospitalizations. We assembled a cohort of 753 adults at our institution undergoing KT from January 1, 2003—December 31, 2007. Two physicians independently reviewed medical records of 237 patients (32%) with early rehospitalization and identified 1) primary reason for and 2) preventability of rehospitalization. Mortality and graft failure were ascertained through linkage to the Scientific Registry of Transplant Recipients. Leading reasons for rehospitalization included surgical complications (15%), rejection (14%), volume shifts (11%), and systemic and surgical wound infections (11% and 2.5%). Reviewer agreement on primary reason (85% of cases) was strong (kappa=0.78). Only 19 rehospitalizations (8%) met preventability criteria. Using logistic regression, weekend discharge (OR 1.59, p=0.01), waitlist time (OR 1.10, p=0.04), and longer initial length of stay (OR 1.42, p=0.03) were associated with early rehospitalization. Using Cox regression, early rehospitalization was associated with mortality (HR 1.55; p=0.03) but not graft loss (HR 1.33; p=0.09). Early rehospitalization has diverse causes and presents challenges as a quality metric after KT. These results should be validated prospectively at multiple centers to identify vulnerable patients and modifiable processes-of-care.

A systematic review of the scientific literature on relationships between management practices used on dairy farms and herd somatic cell count (SCC) was undertaken to distinguish those management practices that have been consistently shown to be associated with herd SCC from those lacking evidence of association. Relevant literature was identified using a combination of database searches (PubMed, Medline, CAB, Agricola, and Web of Science) and iterative screening of references. To be included in the review, a manuscript had to be published after 1979 in French, English, or Dutch; study design had to be other than case report or case series; herds studied had to be composed of ≥ 40 milking cows producing on average ≥ 7,000kg of milk in 305 d; interventions studied had to be management practices applied at the herd level and used as udder health control strategies; and SCC had to be measured using electronic cell counting methods. The 36 manuscripts selected were mainly observational cross-sectional studies; 8 manuscripts dealt exclusively with automatic milking systems and 4 with management of calves and heifers and its effect on SCC in early lactation heifers. Most practices having consistent associations with SCC were related to milking procedures: wearing gloves during milking, using automatic take-offs, using postmilking teat dipping, milking problem cows last, yearly inspection of the milking system, and use of a technique to keep cows standing following milking; all were consistently associated with lower herd SCC. Other practices associated with lower SCC were the use of a freestall system, sand bedding, cleaning the calving pen after each calving, surveillance of dry-cow udders for mastitis, use of blanket dry-cow therapy, parenteral selenium supplementation, udder hair management, and frequent use of the California Mastitis Test. Regarding SCC of heifers, most of the consistent associations reported were related to interventions made during the peripartum period. Studies on automatic milking systems have frequently reported elevation of the herd SCC following transition to the new system. These elevations seemed to be mediated both by the lack of monitoring of chronically infected cows and by an elevated incidence of intramammary infections. By assembling the results reported in many different studies, this review generates a more comprehensive understanding of the management practices influencing SCC and highlights areas of SCC control knowledge that lack evidence of effectiveness.

Provider notification and customized reminders appear promising in helping patients achieve better medication adherence, but these strategies require evaluation in trials powered to detect differences in clinical outcomes.

Background In the context of an aging end-stage renal disease population with multiple comorbidities, transplantation professionals face challenges in evaluating the global health of patients awaiting kidney transplantation. Functional status might be useful for identifying which patients will derive a survival benefit from transplantation versus dialysis. Study Design Retrospective cohort study of wait-listed patients using data on functional status from a national dialysis provider linked to United Network for Organ Sharing registry data. Setting & Participants Adult kidney transplant candidates added to the waiting list between the years 2000 and 2006. Predictor Physical function scale of the Medical Outcomes Study 36-Item Short Form Healthy Survey, analyzed as a time-varying covariate. Outcomes Kidney transplantation; Survival benefit of transplantation versus remaining wait-listed. Measurements We used multivariable Cox regression to assess the association between physical function with study outcomes. In survival benefit analyses, transplant status was modeled as a time-varying covariate. Results The cohort comprised 19,242 kidney transplant candidates (median age, 51 years; 36% black race) receiving maintenance dialysis. Candidates in the lowest baseline physical function quartile were more likely to be inactivated (adjusted HR vs. highest quartile, 1.30; 95% CI, 1.21-1.39) and less likely to undergo transplantation (adjusted HR vs. highest quartile, 0.64; 95% CI, 0.61-0.68). After transplantation, worse physical function was associated with shorter 3-year survival (84% vs. 92% for the lowest vs. highest function quartiles). However, compared to dialysis, transplantation was associated with a statistically significant survival benefit by 9 months for patients in every function quartile. Limitations Functional status is self-reported. Conclusions Even patients with low function appear to live longer with kidney transplantation versus dialysis. For waitlisted patients, global health measures like functional status may be more useful in counseling patients about the probability of transplantation than in identifying who will derive a survival benefit from it.

Background Older patients constitute a growing proportion of U.S. kidney transplant recipients and often have a high burden of comorbidities. A summary measure of health such as functional status might enable transplant professionals to better evaluate and counsel these patients about their prognosis after transplant. Methods We linked UNOS registry data about post-transplant survival with pre-transplant functional status data (physical function [PF] scale of the Medical Outcomes Study Short Form-36) among individuals undergoing kidney transplant from 6/1/2000 – 5/31/2006. We examined the relationship between survival and functional status with multivariable Cox regression, adjusted for age. Using logistic regression models for three-year survival, we also estimated the reduction in deaths in the hypothetical scenario that recipients with poor functional status in this cohort experienced modest improvements in function. Results The cohort comprised 10,875 kidney transplant recipients (KTRs) with a mean age of 50 years; 14% were ≥65. Differences in three-year mortality between highest and lowest PF groups ranged from 3% among recipients <35 years to 14% among recipients ≥65 years. In multivariable Cox regression, worse PF was associated with higher mortality (HR 1.66 for lowest versus highest PF quartiles; p<0.001). Interactions between PF and age were non-significant. We estimated that 11% fewer deaths would occur if KTRs with the lowest functional status experienced modest improvements in function. Conclusions Across a wide age range, functional status was an independent predictor of post-transplant survival. Functional status assessment may be a useful tool with which to counsel patients about post-transplant outcomes.